Maartje M. van den Berg

Epidemiology of Childhood Constipation: A Systematic Review

OBJECTIVE:A systematic review of the published literature was performed to assess the prevalence, incidence, natural history, and comorbid conditions of functional constipation in children.METHODS:Articles were identified through electronic searches in Medline, Embase, Cochrane Central Library, Cinhal and PsychInfo databases. Study selection criteria included: (1) epidemiology studies of general population, (2) on the prevalence of constipation without obvious organic etiology, (3) in children from 0 to 18 yr old, and (4) published in English and full manuscript form.RESULTS:Eighteen studies met our inclusion criteria. The prevalence of childhood constipation in the general population ranged from 0.7% to 29.6% (median 8.9; inter quartile range 5.3–17.4). The prevalence of constipation defined as defecation frequency of <3/wk varied from 0.7% to 29.6% (median 10.4; inter quartile range 1.3–21.3). Identified studies originated from North America (N = 4), South America (N = 2), Europe (N = 9), the Middle-East (N = 1), and Asia (N = 2). Variance of gender specific prevalence was reported in seven studies and five of seven studies reported no significant difference between boys and girls. The age group in which constipation is most common could not be assessed with certainty. Socioeconomic factors were not found to be associated with constipation.CONCLUSION:Childhood constipation is a common problem worldwide. Most studies report similar prevalence rates for boys and girls. Large epidemiologic studies with the use of generally accepted diagnostic criteria are needed to define the precise prevalence of constipation.

The role of a probiotics mixture in the treatment of childhood constipation: a pilot study.

BackgroundInconsistent data exist about the efficacy of probiotics in the treatment of constipation. Several studies in adults with constipation showed positive effects of probiotics on constipation. Inconsistent data exist regarding the effect of a single probiotic strain in constipated children. The aim of this pilot study was to determine the effect of a mixture of probiotics containing bifidobacteria and lactobacilli in the treatment of childhood constipation.MethodsChildren aged 4–16 years with constipation as defined by the Rome III criteria were eligible for the study. During a 4 week period, children received a daily mix of 4 × 109 colony forming units of a probiotic mixture (Ecologic®Relief) containing Bifidobacteria (B.) bifidum, B. infantis, B. longum, Lactobacilli (L.) casei, L. plantarum and L. rhamnosus. Primary outcome measures were frequency of bowel movements (BMs) per week and stool consistency. Secondary outcome measures were number of faecal incontinence episodes per week, abdominal pain and side effects.ResultsTwenty children, 50% male, median age 8 (range 4–16) were included.The frequency of BMs per week increased from 2.0 (1.0–5.0) to 4.2 (0.0–16.0) in week 2 (p = 0.10) and 3.8 (2.1–7.0) in week 4 (p = 0.13). In 12 children presenting with <3 BMs/week, BMs per week increased significantly from 1.0 (0.0–2.0) to 3.0 (0.0–7.0) in week 2 (p = 0.01) and 3.0 (0.0–10.0) in week 4 (p = 0.01). The stool consistency was reported as hard in 7 children at baseline, in 4 children at week 2 (p = 0.23) and in 6 children after 4 weeks of treatment (p = 1.00). A significant decrease in number of faecal incontinence episodes per week was found in the entire group: 4.0 (0.0–35.0) to 1.5 (0.0–14.0) in week 2 (p = 0.01) and 0.3 (0.0–7.0) in week 4 (p = 0.001). The presence of abdominal pain decreased significantly from 45% to 25% in week 2 (p = 0.04) and 20% at week 4 (p = 0.006). No side effects were reported.ConclusionThis pilot study shows that a mixture of probiotics, has positive effects on symptoms of constipation. To confirm these findings, a large randomised placebo controlled trial is required.

Cecostomy in children with defecation disorders

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n = 9), Hirschsprungs disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

A Randomized Controlled Trial of Enemas in Combination With Oral Laxative Therapy for Children With Chronic Constipation

BACKGROUND & AIMS After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children. METHODS In a tertiary hospital in the Netherlands, 100 children, aged 8-18 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies, and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by 1 enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39, and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use. RESULTS Defecation frequency normalized in both groups but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, P = .02, and 5.3 vs 3.9/week, P = .02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (P = .49) and overall success rates (P = .67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group versus 36.1% in the control group. CONCLUSIONS There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.

Helicobacter-induced Gastritis in Mice Not Expressing Metallothionein-I and II*

Background.  Helicobacter pylori a primary cause of gastritis and peptic ulcer disease, is associated with increased production of reactive oxygen species within the gastric mucosa. Metallothionein (MT), a low‐molecular‐weight, cysteine‐rich, metal‐binding ligand, has been shown to sequester reactive oxygen species and reduce tissue damage. This study investigates the role of MT in H. pylori‐induced gastritis in mice.

No Role for Increased Rectal Compliance in Pediatric Functional Constipation

BACKGROUND & AIMS Increased rectal compliance has been proposed to contribute to pediatric functional constipation (FC). We evaluated the clinical relevance of increased rectal compliance and assessed whether regular use of enemas improves rectal compliance in children with FC. METHODS A prospective longitudinal study was conducted on children (8-18 years old) with FC. Pressure-controlled rectal distensions were performed at baseline and at 1 year. Rectal compliance was categorized into 3 groups: normal, moderately increased, or severely increased. Patients were randomly assigned to groups given conventional therapy or rectal enemas and conventional therapy. Clinical success was defined as >or=3 spontaneous defecations per week and fecal incontinence <1 per week. RESULTS Baseline measurements were performed in 101 children (11.0 +/- 2.1 years); rectal compliance was normal in 36%, moderately increased in 40%, and severely increased in 24%. Patients with severely increased rectal compliance had lower defecation frequency (P = .03), more fecal incontinence (P = .04), and more rectal fecal impaction (P < .001). After 1 year, success values were similar between groups: 42% normal, 41% moderately increased, and 40% with severely increased compliance. Barostat studies performed after 1 year in 80 children (37 conventional therapy and 43 rectal enemas in addition to conventional therapy) revealed that rectal compliance had not changed in either group and had not improved in successfully treated patients. CONCLUSIONS Constipated children with severely increased rectal compliance have severe symptoms. However, increased rectal compliance is not related to treatment failure. Regular use of enemas to avoid rectal fecal impaction does not improve rectal compliance in pediatric FC.

242 Brain Processing of Rectal Sensation in Children With Chronic Functional Constipation

Background and Objective: The pathophysiology underlying pediatric chronic functional constipation (FC) is poorly understood. These children often report loss of sensation of urge to defecate. Functional magnetic resonance imaging (fMRI) studies have been used to unravel brain processing of visceral sensation in adults with functional gastrointestinal disorders. However, brain-imaging data are lacking in both adults and children with constipation. The aim is to investigate the cerebral activity in response to rectal distension in children with FC and in healthy controls (HCs). Methods: 15 patients with FC (8M/7F; mean age 14.3 yrs, range 12-18 yrs) and 15 HCs (6M/9F; mean age 20.1 yrs, range 18-21 yrs) participated. Rectal barostat was performed prior to the fMRI scan. A stepwise pressure-controlled distension protocol was used to determine the pressure threshold for urge sensation. Subjects received 2 sessions of 5 stimulations consisting of repetitions of 30 sec of rectal stimulation with previous defined pressure threshold, followed by 30 sec of rest during acquisition blood oxygenation level-dependent (BOLD) fMRI. Images were acquired on a 3Tesla MRI scanner with an 8-channel SENSE head receive coil. A T2*-weighted echo planar imaging sequence was acquired with: TR/TE=3000/30 ms, slice thickness=3.0 mm, voxel size=1.72 x 1.72 x 3 mm, with 40 axial slices, in ascending mode covering the whole brain. fMRI signal differences were analyzed using SPM8 in Matlab, thresholded at p<0.001. Cerebral activation was defined as BOLD increase during rectal distension and cerebral deactivation as BOLD decrease during rectal distension. Results: FC patients had higher thresholds for urgency than HCs (p<0.001). FC patients needed a mean pressure of 18.2 mmHg above MDP to provoke urge sensation, compared to a mean pressure of 8.6 mmHg above MDP in HCs. The groups were differentiated by both activated and deactivated regions in response to rectal distension. FC patients showed activation in the dorsolateral prefrontal cortex and deactivation in the median somatosensory cortex, insula and amygdala. HCs showed deactivation in the same areas, but in contrast, no regions showed significant activation in response to rectal distension. Conclusion: This is the first study evaluating cerebral processing of rectal sensation in constipated patients. FC patients and HCs had a different pattern of cerebral activation and deactivation during rectal distension, suggesting different neural processing of rectal urge sensation in brain regions previously implicated in adult studies using visceral pain stimuli.